MIAMI BEACH — When performing a preoperative assessment of the patient with liver disease, consider specific risk factors during the history and physical examination, said Dr. Paul Martin at a meeting on perioperative medicine sponsored by the University of Miami.
Also assess the likelihood of renal insufficiency and portal hypertension, two of the most concerning perioperative developments.
“Assessing liver patients for surgery is one of the most common consults we get in the hospital,” said Dr. Martin, professor of medicine and chief of hepatology at the University of Miami.
Taking a careful history is essential. “You really want to know if the patient has ever had variceal hemorrhage, ascites, encephalopathy, or jaundice,” Dr. Martin said. Also, if the patient has a relevant surgical history, ask: What did the surgeon say your liver looked like? Did you have any bleeding problems afterward? Correct any coagulopathy before surgery, he added. “Coagulopathy and thrombocytopenia are really the important clues of underlying liver disease.”
Exclude patients with acute hepatitis from surgery. “If patients really had a compelling reason for surgery, I would wait until the liver enzymes are trending downward.”
A patient with cirrhosis is at increased risk for renal insufficiency and/or portal hypertension during surgery. Advise the surgeon and anesthesiologist to watch for onset of renal insufficiency, “because it's a marker of markedly reduced survival,” Dr. Martin said.
Although evidence of renal insufficiency “is what concerns us most” during the perioperative period, avoiding perioperative hypotension also is important, he noted. “Patients with hypotension are poorly tolerant of any drop in blood pressure.”
What has changed in assessment of liver disease is the Model for End-Stage Liver Disease (MELD) score (visit www.unos.org/resources
Operative risk can also be predicted using the Child-Turcotte-Pugh (CTP) classification, which assigns points based on values for bilirubin, albumin, prolonged prothrombin time/INR, ascites, and encephalopathy stage. The classification system correlates with mortality among patients with liver cirrhosis (Hepatogastroenterology 2008;55:1034–40).
A patient with a CTP-A classification generally has no limitations for surgery, Dr. Martin said. Perioperative mortality increases for someone classified as CTP-B, and major hepatic surgery should be avoided. A CTP-C patient is not a candidate for any major elective surgery, and instead should be considered for liver transplantation, he said.
A meeting attendee asked for advice about a common patient type: “I get asked a lot to assess a class Child's B cirrhotic plus, approaching a C, with hip fracture.” Dr. Martin replied: “That patient should not have a general anesthetic, if possible. Use a spinal. There is a substantial risk [of complications], as high as 50%.” He added, “If there is a nonoperative option, that would be the best option, but often, we don't have that luxury.”
Also, cirrhotic patients who experience intraoperative hypotension, who have a respiratory procedure (such as thoracotomy) or who have biliary and liver procedures, are more likely to run into problems after surgery, he said.